arXiv:2510.15859v2 Announce Type: replace Abstract: Reinforcement learning has powered many of the recent breakthroughs in large language models, especially for tasks where rewards can be computed automatically, such as code generation. However, these methods deteriorate in open-ended domains like medical consultation, where feedback is inherently ambiguous, highly context-dependent, and cannot be reduced to a reliable scalar signal. In such settings, RL must either rely on supervision-intensive reward models that often fail to generalize, or it falls into pathological behaviors such as reward hacking - an especially troubling risk for high-stakes medical dialogue. To address these limitations, we introduce ORBIT, an open-ended rubric-based incremental training framework for high-stakes medical dialogue. ORBIT integrates synthetic dialogue generation with dynamically constructed rubrics that serve as adaptive guides for incremental RL. Instead of relying on external medical knowledge bases or handcrafted rule sets, ORBIT uses rubric-driven feedback to steer the learning process. Its judge component can be instantiated with general-purpose instruction-following LLMs, removing the need for any task-specific fine-tuning. Applied to the Qwen3-4B-Instruct model, ORBIT raises the HealthBench-Hard score from 7.0 to 27.5 using only 2k training samples, achieving SOTA performance for models at this scale. With larger rubric datasets, ORBIT-trained models further compete with the strongest open-source baselines on HealthBench-Hard. Our analysis shows that rubric-guided RL consistently improves consultation quality across diverse medical scenarios. We also apply such rubric generation and training pipeline to InfoBench, where ORBIT enhances instruction-following performance, highlighting the generality of rubric-based feedback.